IMMUNIZATION BRANCH

Vaccinations and Medical Exemptions Questions and Answers

What is “herd immunity”?

“Herd immunity”, also known as “community immunity”, is the level of immunity that will prevent the spread of an infectious disease in a population. For measles, for example, the level of vaccination needed to achieve herd immunity is approximately 95%.

If immunity is above the “herd immunity” threshold for a group of people, then an infectious disease might cause a few cases, but it will quickly stop spreading because enough people are protected.

Why is a change in CA’s vaccinations law needed?

A change in the law is needed because some schools are beginning to fall below the 95% vaccination rate, thereby jeopardizing herd immunity, as a result of a growing number of students with medical exemptions. Since this lower vaccination rate at a school leaves the students, staff and community surrounding that school more vulnerable to vaccine-preventable diseases, such as measles, the law is changing to better identify which medical exemptions at a school with lower than 95% vaccination rates meet the standard of medical care and which do not meet the standard of medical care. Those exemptions which meet the standard of medical care will continue. Those which do not, may be revoked.

What is a medical exemption?

Under current California law, a doctor can issue a medical exemption for children whose medical circumstances are such that immunization is not considered safe under the standard of medical care.

Over the past few years, the proportion of students entering kindergarten with medical exemptions has increased. In 2018, 4812 (0.9%) students entered kindergarten with a medical exemption compared with 931 (0.2%) in 2015. Some of these exemptions are concentrated in certain schools which could place them below the 95% herd immunity standard.

Presently, CDPH does not review medical exemptions. This change in the law will allow these medical exemptions to be examined under certain circumstances listed below.

Will the State of California Department of Public Health (CDPH) review all medical exemptions?

By January 1, 2021, the state will be collecting medical exemptions electronically. However, CDPH will not review every medical exemption. Under SB 276 and SB 714, medical exemptions will be reviewed when:

• A school’s immunization rate falls below 95% or

• A doctor writes more than 5 medical exemptions per year beginning January 1, 2020 or

• A school fails to provide reports of vaccination rates to CDPH.

In addition, a medical exemption that does not meet the above criteria may be reviewed, on case by case basis, if CDPH determines it is necessary to protect public health.

How will I submit a medical exemption in the future?

Until January 1, 2021, parents will continue to submit medical exemptions to a school or daycare using a form or letter prepared by their medical provider. Beginning in January 2021 all medical exemptions will be submitted electronically directly into the California Immunization Registry (CAIR) utilizing a standard form.

How can I find out my school’s vaccination rate?

Schools with low vaccination rates are at increased risk for outbreaks of vaccine-preventable diseases. You can look-up your school’s vaccination rate at Shots for School. While the overall vaccination rates of students are high, medical exemptions cluster in some areas and many schools in these areas have vaccination rates less than 95%.

My child has an existing medical exemption. Do they get to keep it?

Yes, all existing medical exemptions continue to be valid except as explained below.

• Parents of students with existing medical exemptions will need to submit a new exemption when the student begins a new ”grade span.” Grade spans are: birth to preschool, kindergarten (including transitional kindergarten) and grades 1-6, and grades 7-12.

• The only existing medical exemptions that could be revoked are those that were written by a doctor subject to disciplinary action by the Medical Board.

My child has a health condition that is not listed in the federal Centers for Disease Control guidelines. Can they still get a medical exemption?

SB 276 and SB 714 do not limit the types of medical conditions that would qualify for a medical exemption. Medical exemptions can be granted for reasons outside of the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), and American Academy of Pediatrics (AAP) guidelines including family medical history, if they are consistent with the standard of medical care for that condition. Doctors issuing a medical exemption will provide a description of the medical basis for the exemption.

Does this change in the law prevent or limit doctors from granting medical exemptions?

No. Doctors will continue to have discretion to determine whether a child should get a medical exemption. When a medical exemption is issued, the doctor will describe the medical basis for the exemption. That basis must be consistent with the standard of medical care for a particular medical condition or align with CDC, ACIP, and AAP guidelines. Medical exemptions will only be reviewed when the immunization coverage at a school falls below 95% or the doctor has issued 5 or more exemptions in a year beginning January 1, 2020 or the school where the child with a medical exemption attends fails to provide immunization reports to CDPH.

Does this change in the law allow a medical exemption not to be accepted?

Yes, under several circumstances. When the new reporting system is in place on January 1, 2021 the state Department of Public Health shall not accept a medical exemption form from a physician or surgeon if there is a pending accusation with the Medical Board of CA or the Osteopathic Medical Board of CA related to immunization standards of care, until the accusation is resolved in favor of the physician and/or surgeon. The CDPH and governing authority (like a school district) shall not accept an exemption form if the physician and surgeon is on probation for an action relating to immunization standards of care. Finally, the CDPH shall not accept a medical exemption form if it determines that a physician’s and/or surgeon’s practice is contributing to a public health risk in one or more communities. In this case, the physician may be barred from submitting an exemption for no less than two years.

Does this change in the law limit doctors to giving 5 medical exemptions a year?

There is no limit to how many medical exemptions a doctor can write. CDPH will review medical exemptions when a doctor writes 5 or more in a year beginning January 1, 2020 to ensure they are being provided consistent with the standard of medical care for a particular medical condition or align with CDC, ACIP, and AAP guidelines.

If a number of exemptions from one doctor are reviewed and there is a pattern of granting exemptions based on clinical information that does not conform to the standard of medical care, there is potential that a provider’s ability to complete further exemptions will be suspended and the doctor will be reported to the California Medical Board.

Who will review my child’s medical exemption?

If a medical exemption is reviewed based on the specific criteria under the new law, clinical staff at CDPH (a physician or a nurse) with expertise in vaccine science including vaccine injury will review the medical exemption. Only the State Public Health Officer, who is a physician, or a physician they designate from the CDPH’s immunization program, can revoke the medical exemption.

Will my child be able to go to school if their medical exemption is reviewed?

Children are able to attend school while CPDH reviews the exemption, as well as during any appeal of a revocation.

What happens if my child’s medical exemption is revoked? Can I appeal?

SB 276 and SB 714 provide an appeal process for parents/guardians if CDPH revokes a medical exemption. The parent/guardian can appeal to an independent expert panel appointed by the California Secretary of Health and Human Services. Information about the appeals process will be provided by CDPH and also posted on the California Health and Human Services Agency’s website. Your child can continue attending school while the revocation of their medical exemption is being appealed.

The expert panel will be made up of independent physicians with expertise in primary care or vaccine science. Their decision must be accepted by the California Secretary of Health and Human Services and is final.

What will my doctor need to do if they issue a medical exemption?

Until January 1, 2021, doctors will prepare a form or letter for parents to submit to their school or daycare. Beginning January 1, 2021, doctors will use an electronic form available through the California Immunization Registry (CAIR). CAIR is a secure computer system that is already used across California that stores children’s immunization (shot) records. It can only be used by doctors, hospitals, public health departments and other selected programs that serve children. It helps kids get their shots on time and stay healthy. It also helps children avoid getting repeat shots when paper records cannot be found. The doctor can send the form to the child’s school, or the school can access the form through CAIR directly.

Why should my child’s immunization information, including medical exemptions, be included in CAIR?

CAIR, the California Immunization Registry, helps to protect your child’s health. A doctor can use the registry to send reminders so your child doesn’t miss shots. Your doctor’s office can also quickly and easily give you a shot record (“yellow card”) for school entry, camp, sports teams or other reasons. A complete record saves you the time and cost of extra doctor appointments, and your child won’t need to repeat shots. If you change doctors within California, the new doctor can get your child’s vaccination records from CAIR.

In addition, having medical exemption information in CAIR allows schools and public health officials to quickly identify them in the event a person may be exposed to a disease and make sure they stay healthy.

Will my child’s information be private?

CDPH, and the CA Immunization Registry (CAIR), comply with state and federal laws to protect privacy. Providers and CAIR staff must abide by confidentiality agreements in order to share patient records. CAIR software has standard security features to protect confidential data from being seen by unauthorized sources, including password protection and data encryption.

By law, CAIR may only be used by authorized people in the medical office or health plan that serves an individual patient. In addition, schools, childcare centers, and certain other agencies can be authorized to look up vaccination records—but only for the children they serve.

CAIR currently has the capability to restrict access to specific data fields to only clinical providers and public health agencies. CDPH will restrict medical exemption form data in a similar fashion.